Healthcare Provider Details

I. General information

NPI: 1366122830
Provider Name (Legal Business Name): JAEHYUN LIM D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2023
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date: 05/24/2024
Reactivation Date: 08/31/2026

III. Provider practice location address

25 STONE STREET GENTLE FAMILY DENTISTRY
AUGUSTA ME
04330
US

IV. Provider business mailing address

5 CONWAY STREET UNIT 205
FREEPORT ME
04032
US

V. Phone/Fax

Practice location:
  • Phone: 207-622-9210
  • Fax:
Mailing address:
  • Phone: 917-582-6791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN5399
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: